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_1. Can be particularly useful for treatment of smaller diverticuli - not amenable to stapler technique _2. Can be used for larger diverticulum as well, alone or in combination with another technique such as the stapler

Surgical technique for use of the Harmonic scalpel for Zenker's Diverticulum

Patients should be intubated and general anesthesia introduced.

Prep and drape the patient in the appropriate fashion with protection of the teeth/gums. The diverticulum is exposed using a Weerda (Karl Storz,Tuttlingen, Germany) diverticuloscope placed in the hypopharynx with the anterior portion of the diverticuloscope placed in the esophagus and the posterior portion in diverticulum, thereby revealing the shared wall.

Optionally, a bougie can placed in the esophagus to confirm correct identification of the diverticulum lumen from the esophageal lumen. The patient is then placed in suspension. A rigid zero degree Storz endoscope (Karl Storz, Tuttlingen, Germany) is used for visualization and documentiation during the procedure.

The endoscopic Curved Shears (LCS) - Pistol grip 36 cm Harmonic scalpel 15 mm active blade - 5.5 mm diameter (ref LCSC5) (Ethicon Endo-Surgery, Inc, Guaynabo, Puerto Rico) is inserted. The blades are then opened around the septum and then closed around the septum. The Harmonic scalpel settings are 3 and 5, as minimum and maximum values respectively. The harmonic scalpel is then used to cauterize and divide the tissue. – initially at the minimal level, however, after the first cuts, the intervening septum is reassessed; if necessary, additional dividing cuts are made at the maximal level with greater efficacy.

Once complete division is achieved and the area is meticulously inspected for hemostatsis and appropriate mucosal collapse, the diverticuloscope is removed. The patient is awakened in the OR, extubated, and taken to post op recovery.

Post op

Admit to hospital - recovery

NPO for first night with IVF

POD#1 start on clear liquid diet, if does well advance diet to pureed/soft diet for lunch. If does well at lunch can discharge afternoon of POD#1 on soft diet to advance as tolerated over next one to two weeks to regular diet

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